Cardiovascular drugs 2 Flashcards by Ingrid Bekono

How do you diagnose HTN?

Record the lowest of 2 consecutive measurements in clinic
If above 140/90 offer ABPM
If unsuitable offer HBPM
Cut off for HTN on ABPM/HBPM is >135/85

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Which activities/errors surrounding BP taking will affect the result?

Cuff too small
Cuff over clothing
Back/feet unsupported
Legs crossed
Patient not at rest for >5 minutes
Patient talking
Pain

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Define the following terms:

a) (True) Normotensive
b) (True) Hypertensive
c) White coat hypertension
d) Masked hypertension

a) Normal ABPM/HBPM + clinic BP
b) HTN on ABPM/HBPM + clinic BP
c) Normotensive on ABPM/HBPM, HTN in clinic
d) Normotensive in clinic but HTN by HBPM/ABPM

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> 90% of HTN are primary cases

Give 5 causes of secondary HTN

Renal disease- renovascular disease, renal parenchymal disease

Endocrine- Crohns, Cushings, Phaechromocytoma

Drugs- COCP, steroids, NSAIDs, cocaine, EPO

Vascular- coarctation of the aorta (presents in radio-femoral delay in young)

Other- OSA, pregnancy

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Give 5 factors which contribute to the development of HTN

High BMI

> 14 units of alcohol/week

Salt intake

Lack of exercise

Stress

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What are the risk factors for HTN?

M>F
Age
FMHx
Ethnicity (Africans, Asians)
Smoking
Cholesterol
Diabetes

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Describe the pathophysiology of HTN

BP = CO x SVR

- CO= HR x SV

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What are the symptoms of HTN?

Asymptomatic mainly

- Headache, blurred vision, dizziness, SOB, palpitations, epistaxis (nose bleed)

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How do you examine a patient with HTN?

CV / Resp

- Abdo: for secondary causes e.g. Polycystic kidneys, renal masses

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What investigations would you do in HTN?

Bloods: U&E, LFTs, Lipid profile, Glucose/HbA1c

Urinalysis

Haematuria: indicates possible renal cause
Proteinuria

ECG: for LVH, AF

-Fundoscopy to look for evidence of hypertensive retinopathy (best done by ophthamologists)

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What is the prognosis if there is target organ damage?

HTN increases CV risk if target organ damage is present that risk increases more

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First line pharmacological treatment for <55 patient not of Black origin

ACE inhibitor e.g. Ramipril

If not tolerated (due to cough) give ARB e.g. Losartan

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First line pharmacological treatment for >55 yo patient, or black

CCB e.g. Amlodipine

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If first line treatment is in effective what next?

And if this doesnt work?

Add a thiazide like diuretic

e.g. Indapamide

ACEi/ARB + CCB + Thiazide like diuretic

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What is considered resistant HTN?

Management?

Requires >3 antihypertensives

Ask about adherance to medication
Check for postural hypertension

Consider adding

Low dose spironlactone is K<4.5
a-blocker/b-blocker if K>4.5

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Give three side effects of amlodipine

Muscle cramps
Leg swelling
Constipation
Flushing
Palpitations
Headaches

What tests should be done before starting on ACE-i?

Rules for titration?

Coprescription?

Check serum creatinine and K before starting
If K>normal, use is contraindicated
With every dose increment, repeat blood tests
If creatinine rises> 30%; GFR falls >25% or K>6 stop drug, repeat tests and exclude other causes
Exhibit caution when coprescribed with spirinolactone

ACEi and ARBs are contraindicated in pregnancy and breast feeding. What alternatives can be used?

Labetalol
Methyldopa
Nifedipine/Amlodipine

How do BP targets differ based on age when monitoring the effects of treatment

Age <80 years:
• Clinic BP <140/90 mmHg
• ABPM/HBPM <135/85 mmHg

Age ≥80 years:
• Clinic BP <150/90 mmHg
• ABPM/HBPM <145/85 mmHg

How do proteinuria targets differ with ACR

Proteinuria low if
Albumin:creatinine (ACR) <70
or protein:creatinine (PCR)<100
Target BP should be <140/90

Proteinuria high is
ACR >70 or PCR >100
Tighter BP target off <130/80

Discuss the use of ACEi and ARBs in patients with proteinuria

They should be used in patients with urinary ACR>30 or PCR>50

Also in diabetic patients with microalbuminuria

Why does HTN treatment fail?

Pseudo-resistant HTN: due to non adherence, white coat effect
Secondary hypertension: underlying cause persists
Resistant HTN

Which patients are particularly at risk of developing hyperkalaemia?

Those with impaired renal function

What considerations need to be made when treating an older patient?

Treat in accordance to higher targets of 150/90
Check for postural hypertension
Use clinical judgement

Define the two types of hypertensive crises

1) Hypertensive emergency - severe HTN (BP>180/110) with acute damage to the target organs - need to lower BP in minutes-hours 2) Hypertensive urgency - severe hypertension without acute damage to the target organs - lower BP in 1-2 days

What are the symptoms of a hypertensive crisis?

- Asymptomatic - Headache - Epistaxis - Presyncope - Palpitations - Chest pain - Dyspnoea - Neurological deficit

When and how should statins be used for primary prevention of CVD?

- CVD risk shouldl be estimated - Offer lifestyle modification first - Offer atorvastatin if risk >10% or if above 85yo - Offer in diabetes, CKD, familial hypercholesterolemia

What end organ damage can occur as a result of a hypertensive crisis?

- Eyes: papilloedema - Brain: encephalopathy, stroke - Heart: pulmonary oedema, MI - Kidneys: AKI - Aortic dissection

When and how should statins be used for secondary prevention of CVD?

- Do not delay initiation to manage modifiable risk factors | - Start statins in those with CVD

When should you not use a risk assessment tool to assess CVD risk?

- In those with eGFR<60ml/min/1.73m | - And/or those with albuminuria

Which blood tests should be done before the initiation of statin therapy?

- Lipid measurement - LFTs (3x upper limit of normal) - Renal function - HbA1C - TSH - CK (5x upper limit of normal)

Is any monitoring necessary with statins?

After three months - measure lipid: should be a 40% reduction in non-HDL cholesterol - measure LFTs - CK if symptoms - Annual medication review

If statins are not tolerated what is the alternative?

Stop, reduce dose, or switch statin Seek specialist input Avoid fibrates Ezetimibe - may be coadministered with statin if appropriate

A patient presents with hypertriglycerridaemia. What should you exclude first? For each TG range give the

- Exclude excess alcohol and poor glycaemic control TG>20mmol/l- refer to specialist TG: 10-20mmol/l- do a repeat fasting sample within 2 weeks. If >10mmol/l refer TG: 4.5-9.9mmol/l- check CVD risk and correlate with cholesterol Specialsits will give omega 3, fenofibrates

A 62-year-old man has recently been started on atorvastatin 80mg following an MI and complains of muscle aches and weakness. Investigation Results:Serum creatine kinase 2306 U/L (24–195). What is the most appropriate therapeutic decision regarding the atorvastatin prescription?

Lower the dose Serum CK raised due to myopathy Risk of rhabdomyolysis (more severe myopathy) Those at increased risk of myopathy are (diabetics, elderly, hypothyroidism, liver or kidney disease)

Which risk calculators are used for CV risk?

QRISK2/3 - provide 10 year CV risk JBS3- provides lifetime risk

How do statins reduce CVD risk?

Increase uptake on LDL from circulation Work independent of cholesterol lowering

What lifestyle management is given for HTN?

- Weight reduction (BMI between 20-25) - DASH eating plan - Sodium restriction - Physical activity - Alcohol moderation